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ONSITE WASTIL•OVATER TREATMENT SYSThld PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3m FL-STOCKTON CA 95202 - <br /> NON-REFUNDABLE PERMIT (ATE ISSUE 0 <br /> �(I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS d/l'9'L T /-l7./� e SE �l�- CITY/ZIP ��J VJy' <br /> CROSS STREET /�F/t'AN11*'1✓1p ^P - 'JJT APN��y yso V PARCELSIZE <br /> OWNER NAME 0-51 /W� CO/y{ // 7 IYPAf./T] PHONE�?cn) 936 -51001 <br /> OWNER ADDRESS 1160 / t4 , t±ou5e /� (,� CITY/STATE/ZIP =z('Q(�t,�t C ?53011CONTRACTOR <br /> Pxorve <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEFTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ E CINEER DESIGNED/A ERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> n <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OYHER ^ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TON RES. ft FOUNDATION R PROPERTY LME R <br /> ❑ LIFT STATION E Jam! TYPEIF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LIN(Di <br /> ❑ L - H G CHAMBE #OF LINES NGTH OF LINES R <br /> O NEAREST WELL ft FOUNDATION R PROPERTY LMELlFILTER BEDIDTH ft LENGTH DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOU*ATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH Alk/ ft DEPTH R <br /> DISTANT To NEAREST IYELL J, OUNDATION R PROPERTY LME R <br /> El SUMPS WIDTH.-• - R LENGTH ft DEPTH ft <br /> DISTANCE To N&4$tEST WELL ft FOUNDATION R PROPERTY LME R <br /> ❑ DISPOSAL P DS y( I ft LENGTH ft DEPTH ft <br /> ANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME R <br /> ❑ SEEPAG P Numaea WIDTH ft - DEPTH ft <br /> DISTANfTO NEAREST WELL ft FOUNDATION R PROPERTY LME R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> a 1 <br /> SIGNED _ TT E �- DATE � s'OS <br /> -1.._. .._.1..__. <br /> 41. <br /> i ! <br /> I t <br /> 1 <br /> r <br /> f t :_ <br /> EPARTMENTUSE NLY <br /> Application Accepted By Area 0 Employee ID# d 0 C) <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump Soil Character: ,p Al-q4) <br /> � <br /> COMMENTS Ila .ni /C i�kI�C0�2/�Q7 / �I,�x 4) <br /> ( <br /> PE SC Received hecld{/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Reouest# <br /> Lf2,24 <br /> 0 S r <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />